Claims and Appeals Reform Held Until Year-end

If you’ve been waiting for claims and appeals reform as outlined in the health reform bill, you’ll have to wait until next year.

The U.S. Department of Labor, Health and Human Services, and the Treasury (the Departments) announced via a technical release that enforcement of a key health reform provision will be postponed for a second time, from July 1, 2011 until Jan. 1, 2012 to allow more time for payers and others to comment. Public Health Service Act revisions and related provisions in the Patient Protection and Affordable Care Act seek to speed appeals of denied claims while making the decision process more transparent.

In the release, officials say, “The Departments intend to issue an amendment to the 2010 interim final regulations in the near future that takes into account comments and other feedback received from stakeholders on the 2010 interim final regulations, and makes modifications to certain provisions of the 2010 interim final regulations.” The release continues, saying that the delay is intended to ensure plan participants and beneficiaries have these opportunities outlined in the health reform bill:

  • Fuller and fairer processing of claims
  • Right to appeal denied claims
  • Right to obtain external review of denials on appeal

The delay, the Department of Health and Human Services (HHS) says, will help federal and state agencies, employers, payers, and others develop regulations and implementation plans that will be easily and clearly launched. Many stakeholder groups had complained that it would take time to properly implement the rules.

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HHS says the rules outlined in 2010 will hold until the new rules take affect. T.R. 2010-02, which explains the rules, can be found in the Department of Labor website.

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